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Guidelines for Early Detection of Breast Cancer in Brazil. III – Challenges for Implementation

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Guidelines for Early Detection of Breast Cancer in Brazil. III – Challenges for Implementation ESPAÇO TEMÁTICO: CÂNCER DE MAMA NO BRASIL THEMATIC SECTION: BREAST CANCER IN BRAZIL Guidelines for early detection of breast cancer in Brazil. III – Challenges for implementation Diretrizes para detecção precoce do câncer de mama no Brasil. III – Desafios à implementação Arn Migowski 1,2 Maria Beatriz Kneipp Dias 1 Directrices para la detección precoz del cáncer Paulo Nadanovsky 3,4 de mama en Brasil. III – Desafíos Gulnar Azevedo e Silva 3 1 a la implementación Denise Rangel Sant’Ana Airton Tetelbom Stein 5 doi: 10.1590/0102-311X00046317 Abstract Correspondence A. Migowski Instituto Nacional de Câncer José Alencar Gomes da Silva. The objective of the current article is to present the main challenges for the Rua Marquês de Pombal 125, Rio de Janeiro, RJ 20230-092, implementation of the new recommendations for early detection of breast Brasil. cancer in Brazil, and to reflect on the barriers and the strategies to overcome [email protected] them. The implementation of evidence-based guidelines is a global challenge, 1 and traditional strategies based only on disseminating their recommendations Instituto Nacional de Câncer José Alencar Gomes da Silva, Rio de Janeiro, Brasil. have proven insufficient for changing prevailing clinical practice. A major 2 Instituto Nacional de Cardiologia, Rio de Janeiro, Brasil. challenge for adherence to the new guidelines for early detection of breast can- 3 Instituto de Medicina Social, Universidade do Estado do Rio de cer in Brazil is the current pattern in the use of mammographic screening in Janeiro, Rio de Janeiro, Brasil. the country, which very often includes young women and a short interval be- 4 Escola Nacional de Saúde Pública Sergio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, Brasil. tween tests. Such practice, harmful to the population’s health, is reinforced by 5 Universidade Federal de Ciências da Saúde de Porto Alegre, the logic of defensive medicine and the dissemination of erroneous informa- Porto Alegre, Brasil. tion that overestimates the benefits of screening and underestimates or even omits its harms. In addition, there is a lack of policies and measures focused on early diagnosis of symptomatic cases. To overcome these barriers, changes in the regulation of care, financing, and implementation of shared decision- making in primary care are essential. Audit and feedback, academic detail- ing, and the incorporation of decision aids are some of the strategies that can facilitate implementation of the new recommendations. Breast Neoplasms; Early Detection of Cancer; Mass Screening; Mammography; Health Plan Implementation This article is published in Open Access under the Creative Commons Attribution license, which allows use, distribution, and reproduction in any medium, without restrictions, as long as the original work is correctly cited. Cad. Saúde Pública 2018; 34(6):e00046317 2 Migowski A et al. Introduction In Brazil, the debate on breast cancer control in the last 15 years (whether from the perspective of academia, administrators, healthcare providers, or media coverage) has focused on mammographic screening. This central position of mammography has accumulated gradually through the legiti- macy of the technical and scientific discourse and the ease in implementation of mass screening in the country 1. The current challenge is the implementation of new recommendations by the Brazilian Ministry of Health for the early detection of breast cancer in the country 2, elaborated on the basis of a new methodological approach that expands the view of early detection beyond screening to include strategies for early diagnosis of cases with suspicious signs and symptoms 1. The implementation of evidence-based guidelines is a global challenge, and strategies that only use dissemination of the guidelines’ recommendations have proven insufficient to generate changes in prevailing clinical practice 3. The widespread notion of health as access to more medical technologies 4 adds to the dif- ficulties by health professionals and the general population in assimilating the proposed new methods and practices and the dependence on structural and administrative conditions in the health system for healthcare to actually occur. The aim of this article is to present the main challenges to implementation of the new recommen- dations for early detection of breast cancer in Brazil from the authors’ perspective, as well as to reflect on the barriers that can impact the implementation of the guidelines and the strategies to overcome those barriers. Challenges and barriers to implementation of the new guidelines In 2014, according to data from the Brazilian Ambulatory System of the Unified National Health System (SIA-SUS), only 46 services in the entire country reported having performed all the neces- sary procedures for diagnostic confirmation in women with suspicious lesions or alterations 5. The difficulty in supplying all the procedures in a single service can have a direct impact on the strategy of early diagnosis, by generating a demand for unnecessary intermediate medical consultations. In Brazil, from 2010 to 2011, 40% of breast cancer cases reached oncology referral hospitals without a definitive diagnosis, which indicates insufficient structuring of secondary care 5. This disorganization of diagnostic investigation is aggravated by the increasing demand associ- ated with mammographic screening. In the 2013 edition of the Brazilian National Health Survey (PNS), the proportion of women in the target population 50 to 69 years of age that reported having had a mammogram in the two years prior to the survey was 60%, varying across regions of the country 6. The highest coverage rates were in the South and Southeast (68 and 65%, respectively), and the lowest was in the North (39%), with intermediate coverage in the Central (56%) and Northeast (48%). These data indicate a 6% overall increase in the country compared to another national survey conducted 5 years before 6. Another recent national study estimated lower coverage rates in the target population, based on data from the SIA-SUS database 7. Still, the coverage in this study may have been underes- timated, given the provision of mammographic screening in private clinics 8. Notwithstanding this discussion on the true magnitude of screening, there has been an undeniably important increase in screening coverage in the country in the last decade 9. Still, while there has been an increase in coverage due to government incentives, there has also been evident non-adherence to the Brazilian Ministry of Health guidelines on target population and periodicity of mammographic screening, as recommended in the national consensus document in 2004, that is, biennial screening in the 50-69 year age bracket 10. According to data from the Breast Cancer Information System (SISMAMA) of the SUS, approximately half of screening mammograms are performed outside the 50 to 69 year target population, the majority in women under 50 years 11, despite national guidelines that have existed for more than 10 years recommending the target age bracket 10. Based on national data in the SIA-SUS in 2010, screening coverage in women 40-49 years of age was similar to that of the target population (50 to 69 years) 7. A recent study analyzing data from the PNS also showed that the percentage of women with a medical prescription for mammographic Cad. Saúde Pública 2018; 34(6):e00046317 GUIDELINES FOR EARLY DETECTION OF BREAST CANCER 3 screening in Brazil in the 40 to 49-year bracket did not differ from the 50-69-year bracket, either in the public healthcare system (SUS) or in the private system 12. As for screening intervals, in the public healthcare system (SUS) there is a heavy predominance of short intervals between screening tests, i.e., 45% with annual intervals or shorter, and 32% with intervals between one and two years 11. According to a recent hospital-based study in southern Bra- zil, annual mammographic screening was more common in women 50 years or older than in women from 40 to 49 years 13. The same study showed that users of the public system (SUS) were more likely to undergo annual screening when compared to those with private health plans (62% versus 48%) 13. There are various complex determinants of this pattern in the use of mammographic screening in Brazil, which act as barriers to the paradigm shift in the new guidelines 2. One of the pillars in the development of mammographic screening’s global hegemony as a health intervention, among physi- cians, administrators, the media, and the general population, was the dissemination of the simplistic, commonsensical strong idea of “the sooner breast cancer is detected, the better”. The hypothesis that emerged in the mid-20th century was that breast cancer metastasis was determined by the tumor’s size, which in turn was a proxy for the tumor’s age 14. According to this hypothesis, the smaller the tumor when detected, the higher the odds of avoiding radical surgeries, the lower the odds of metasta- sis, and the longer the survival 15. This theory is still globally hegemonic in the media, organized civil society, and even among health professionals, ignoring decades of research demonstrating the het- erogeneity of breast cancer and the existence of other prognostic factors – in addition to tumor size – capable of determining its biological behavior, in addition to such phenomena as overdiagnosis and overtreatment. The motto “Catch it as soon as possible, before it’s too late”, – repeated exhaustively by advocates of mammographic screening –, not only overestimates the importance of screening but can also discourage symptomatic women from seeking care, due to their disbelief in their prognosis, when in reality the greatest progress in the last three decades was precisely in the improvement of treatment results for locally advanced breast cancer due to strides in adjuvant therapy 16. The belief that only detection by screening results in a favorable prognosis is further reflected in the shaping of healthcare, where early diagnostic strategies are relegated to a secondary role.
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